BACKGROUND: It remains unknown if pediatric patients failing initial noninvasive ventilation (NIV) experience worse clinical outcomes than those successfully treated with NIV or those primarily intubated. METHODS: This was a single-center, retrospective review of patients admitted with acute respiratory failure to the University of Michigan pediatric intensive care or cardiothoracic ICUs and receiving NIV or invasive mechanical ventilation as first-line therapy. RESULTS: One hundred seventy subjects met inclusion criteria and were enrolled: 65 NIV success, 55 NIV failure, and 50 invasive mechanical ventilation alone. Of those failing NIV, median time to intubation was 1.8 (interquartile range [IQR] < 1–7) h. On multivariable regression, ICU-free days were significantly different between groups (NIV success: 22.9 ± 6.9 d; NIV failure: 13.0 ± 6.6 d; invasive ventilation: 12.5 ± 6.9 d; P < .001 across all groups). Multivariable regression revealed no difference in ventilator-free days between NIV failure and invasive ventilation groups (15.4 ± 10.1 d vs 15.9 ± 9.7 d, P = .71). Of 64 subjects (37.6%) meeting Pediatric Acute Lung Injury Consensus Conference pediatric ARDS criteria, only 14% were successfully treated with NIV. Ventilator-free days were similar between the NIV failure and invasive ventilation groups (11.6 vs 13.2 d, P = .47). On multivariable analysis, ICU-free days were significantly different across pediatric ARDS groups (P < .001): NIV success: 20.8 + 31.7 d; NIV failure: 8.3 + 23.8 d; invasive alone: 8.9 + 23.9 d, yet no significant difference in ventilator-free days between those with NIV failure versus invasive alone (11.6 vs 13.2 d, P = .47). CONCLUSIONS: We demonstrated that critically ill pediatric subjects unsuccessfully trialed on NIV did not experience increased ICU length of stay or fewer ventilator-free days when compared to those on invasive mechanical ventilation alone, including in the pediatric ARDS subgroup. Our findings are predicated on a median time to intubation of < 2 h in the NIV failure group and the provision of adequate monitoring while on NIV.

Pediatrics and Critical Care Medicine Universidad Internacional del Ecuador and Pediatric Intensive Care Unit Hospital de los Valles and Hospital SOLCA Quito, Ecuador * See also p. e25. Dr. Campos is employed part-time by an Ecuadorian pharmaceutical laboratory.

Crit Care Med 2012 Vol. 40, No. 11 The death of a child is an overwhelming experience for most parents (1, 2). Many personal and interpersonal needs arise that are often shaped by the setting and circumstances in which the child’s death occurred. For example, the needs of parents bereaved in pediatric intensive care units (PICUs) are often related to the highly technological environment, the multitude and diversity of staff, and the rapid pace of complex decision making (3). Parents bereaved in PICUs are at high risk for complicated grief, a condition characterized by intense and prolonged symptoms that interfere with daily functioning (4–6). Health professionals working in PICUs must seek to understand parents’ needs to provide appropriate supportive care and promote adjustment to loss. Most prior studies evaluating the needs of parents bereaved in PICUs have used qualitative methods such as interviews and focus groups (3, 7–12). Findings from these studies provide insight into parents’ perspectives of their needs based on their lived experiences. Some identified needs include maintaining the parent-child relationship; honest communication; kindness and compassion from PICU staff; privacy, enough time, and a reverent atmosphere near the time of death; support from family and friends; Copyright © 2012 by the Society of Critical Care Medicine and Lippincott Williams and Wilkins DOI: 10.1097/CCM.0b013e31825fe164 Objectives: To evaluate the reliability and validity of the Bereaved Parent Needs Assessment, a new instrument to measure parents’ needs and need fulfillment around the time of their child’s death in the pediatric intensive care unit. We hypothesized that need fulfillment would be negatively related to complicated grief and positively related to quality of life during bereavement. Design: Cross-sectional survey. Setting: Five U.S. children’s hospital pediatric intensive care units. Subjects: Parents (n = 121) bereaved in a pediatric intensive care unit 6 months earlier. Interventions: Surveys included the 68-item Bereaved Parent Needs Assessment, the Inventory of Complicated Grief, and the abbreviated version of the World Health Organization Quality of Life questionnaire. each Bereaved Parent Needs Assessment item described a potential need and was rated on two scales: 1) a 5-point rating of importance (1 = not at all important, 5 = very important) and 2) a 5-point rating of fulfillment (1 = not at all met, 5 = completely met). Three composite scales were computed: 1) total importance (percentage of all needs rated ≥4 for importance), 2) total fulfillment (percentage of all needs rated ≥4 for fulfillment), and 3) percent fulfillment (percentage of important needs that were fulfilled). Internal consistency reliability was assessed by Cronbach’s α and Spearman-Brown–corrected split-half reliability. Generalized estimating equations were used to test predictions between composite scales and the Inventory of Complicated Grief and World Health Organization Quality of Life questionnaire. Measurements and Main Results: Two items had mean importance ratings <3, and 55 had mean ratings >4. reliability of composite scores ranged from 0.92 to 0.94. Total fulfillment was negatively correlated with Inventory of Complicated Grief (r = −.29; p < .01) and positively correlated with World Health Organization Quality of Life questionnaire (r = .21; p < .05). Percent fulfillment was also significantly correlated with both outcomes. Adjusting for parent’s age, education, and loss of an only child, percent fulfillment remained significantly correlated with Inventory of Complicated Grief but not with World Health Organization Quality of Life questionnaire. Conclusions: The Bereaved Parent Needs Assessment demonstrated reliability and validity to assess the needs of parents bereaved in the pediatric intensive care unit. Meeting parents’ needs around the time of their child’s death may promote adjustment to loss. (Crit Care Med 2012; 40:3050–3057)

Objectives: To evaluate the reliability and validity of the Bereaved Parent Needs Assessment, a new instrument to measure parents' needs and need fulfillment around the time of their child's death in the pediatric intensive care unit. We hypothesized that need fulfillment would be negatively related to complicated grief and positively related to quality of life during bereavement.Design: Cross-sectional survey.Setting: Five U. S. children's hospital pediatric intensive care units.Subjects: Parents (n = 121) bereaved in a pediatric intensive care unit 6 months earlier.Interventions: Surveys included the 68-item Bereaved Parent Needs Assessment, the Inventory of Complicated Grief, and the abbreviated version of the World Health Organization Quality of Life questionnaire. Each Bereaved Parent Needs Assessment item described a potential need and was rated on two scales: 1) a 5-point rating of importance (1 = not at all important, 5 = very important) and 2) a 5-point rating of fulfillment (1 = not at all met, 5 = completely met). Three composite scales were computed: 1) total importance (percentage of all needs rated >= 4 for importance), 2) total fulfillment (percentage of all needs rated >= 4 for fulfillment), and 3) percent fulfillment (percentage of important needs that were fulfilled). Internal consistency reliability was assessed by Cronbach's alpha and Spearman-Brown-corrected split-half reliability. Generalized estimating equations were used to test predictions between composite scales and the Inventory of Complicated Grief and World Health Organization Quality of Life questionnaire.Measurements and Main Results: Two items had mean importance ratings <3, and 55 had mean ratings >4. Reliability of composite scores ranged from 0.92 to 0.94. Total fulfillment was negatively correlated with Inventory of Complicated Grief (r = -.29; p < .01) and positively correlated with World Health Organization Quality of Life questionnaire (r = .21; p < .05). Percent fulfillment was also significantly correlated with both outcomes. Adjusting for parent's age, education, and loss of an only child, percent fulfillment remained significantly correlated with Inventory of Complicated Grief but not with World Health Organization Quality of Life questionnaire.Conclusions: The Bereaved Parent Needs Assessment demonstrated reliability and validity to assess the needs of parents bereaved in the pediatric intensive care unit. Meeting parents' needs around the time of their child's death may promote adjustment to loss. (Crit Care Med 2012; 40: 3050-3057)

OBJECTIVE:To test the hypothesis that a normal capillary refill time (CRT) ≤ 2 seconds is associated with superior vena cava oxygen saturation (ScvO₂) ≥ 70% in critically ill children. STUDY DESIGN:Two-year, prospective study in a tertiary-level pediatric intensive care unit. Whenever ScvO₂ measurements were obtained, central (forehead/sternum) and peripheral (finger/toe) CRTs were concomitantly assessed. RESULTS:Central and peripheral CRTs ≤ 2 seconds were both associated with ScvO₂ ≥ 70% (P < .01). Sensitivity/specificity analyses revealed that central CRT ≤ 2 seconds demonstrated a sensitivity of 84.4%, specificity of 71.4%, positive predictive value of 93.1%, and negative predictive value of 50.0% in predicting ScvO₂ ≥ 70%. Peripheral CRT ≤ 2 seconds had a sensitivity of 71.9%, specificity of 85.7%, positive predictive value of 95.8%, and negative predictive value of 40.0% in predicting ScvO₂ ≥ 70%. CONCLUSIONS:A normal CRT ≤ 2 seconds can be predictive of ScvO₂ ≥ 70%. Our study corroborates the recommendations of the Pediatric Advanced Life Support curricula targeting a normal CRT ≤ 2 seconds as a therapeutic endpoint for goal-directed shock resuscitation. This clinical target remains particularly relevant in community hospitals when the ability to obtain central venous catheter access may be limited and ScvO₂ data unavailable.

Bill James, baseball statistician and author, tells the story of hungry cavemen sitting about a campfire, waiting for tomatoes to ripen. One has the inspiration to throw an ox on the fire, and the first barbecue ensued and was endured. After eating, the conversation goes something like this. "There were some good parts." "Yeah, but there were some bad parts." And the smart one says, "This time, let's not eat the bones." The evolution of patient selection criteria for the use of extracorporeal support (ECLS) is a bit like those cavemen and their first barbecued ox. Extracorporeal life support technology and application to patient care is the unique result of a long standing history of ambitious attempt, evaluation, debate, collaboration and extension.

Department of Pediatrics and Communicable Diseases; University of Michigan; Ann Arbor, MI The author has not disclosed any potential conflicts of interest.

Anticoagulation for extracorporeal life support (ECLS) is routinely achieved using heparin, which can be difficult in patients suspected of having heparin-induced thrombocytopenia. We describe a case series of five patients in which we used argatroban, a direct thrombin inhibitor, as an alternative to heparin for systemic anticoagulation during ECLS in patients suspected to have heparin-induced thrombocytopenia. Argatroban was used to achieve target systemic anticoagulation for activate clotting times between 210 and 230. Duration of argatroban use while on ECLS ranged from 6 to 184 hours. Argatroban dosage ranged from 0.2 to 3.5 microg/kg/min. Activated clotting times showed good agreement with aPTT. In conclusion, we illustrate that argatroban is a reasonable alternative to heparin anticoagulation for patients requiring ECLS.

Bjornson CL, Klassen TP, Williamson J, Brant R, Mitton C, Plint A, et al. Pediatric Emergency Research Canada Network. N Engl J Med 2004;351:1306-13. Context The benefits of dexamethasone treatment for moderate-to-severe croup are well established. However, most children with croup have mild symptoms, and it is unknown whether they would derive the same degree of benefit from dexamethasone treatment as children with more severe disease. Objectives To determine whether dexamethasone treatment of mild croup would reduce the incidence of a return visit to a medical care provider for croup and the associated economic costs. Design A multi-institutional, double-blinded, randomized, controlled trial. Setting Four pediatric emergency departments in Canada. Participants Children with mild croup (n = 720), defined as having a score of ≤2 on the croup scoring system of Westley et al. Interventions Children were randomly assigned to receive one oral dose of either dexamethasone (0.6 mg/kg) or placebo. Main outcome measures The primary outcome was a return to a medical care provider within seven days of initial treatment. Secondary outcomes that were measured included symptom scores on days 1, 2, and 3 after treatment; economic costs; hours of sleep lost by the child; and parental stress. Results Baseline clinical characteristics were similar in the two groups. Return to medical care was significantly lower in the dexamethasone group (7.3% vs 15.3%, P < .001, number needed to treat = 13). In the dexamethasone group, there was quicker resolution of croup symptoms (P = .003), less lost sleep (P < .001), and less stress on the part of the parent (P < .001). Conclusions For children with mild croup, dexamethasone is an effective treatment that results in consistent and small but important clinical and economic benefits. Although the long-term effects of this treatment are not known, the authors advocate the use of dexamethasone in most if not all children with croup. Comment This is a well-designed, methodologically sound, and statistically robust study. The premise is intriguing: Will the mildest form of croup respond to steroid treatment in an effective and economically sound manner? The authors have added substantial value to the paper by cleverly analyzing secondary outcomes important to health care economists, parents, primary care providers, and the child. The latter outcomes have never before been studied. Previous studies of the efficacy of steroids are flawed because of the inclusion of children with a broad spectrum of severity of symptoms. This study precisely defines the clinical syndrome and thus generates an unbiased estimate of children returning for visits to a primary care provider. The proportion of children who required return visits to a care provider decreased by more than 50% in the dexamethasone-treated group. Data for the economic analysis included costs for both the third party payer (the provincial government) and the family during the 21 days after enrollment. The cost savings were small in magnitude per case ($93 ± $215 for placebo vs $72 ± $170 for dexamethasone). We should remember, however, that the transparent savings to the parents of a healthy, sleeping child are difficult to measure. Further, a small savings per case multiplied by the large number of mild cases of a common illness can have a sizable impact on costs. This unique study also explores nontraditional outcomes from a family perspective. For example, the authors found that during the first 3 days after treatment, the average amount of sleep the child lost was reduced by 30% in the steroid-treated group. This finding, while invisible to the treating physician, would be especially important to the family. The authors have performed an important study, with clinical, economic, and quality-of-life outcomes. This rigorous study provides evidence for parents and clinicians that dexamethasone is effective in the mildest form of croup.

15. Anderson RL: Golbus MS, CmTy CJR, CalIen PW, Hastrup WH (t990) Central nervous system damage and other anomalies in surviving fetus following second trimester antenatal death of cotwin. Prenat Diagn 10:513-518 16. Mannino FL, Lyons Jones K, Benirschke K (1977) Congenital" skin defects and fetus papyracens. J Pediatr 91:559-564 17. Hughes HE, Miskin M (1986) Congenital microcephaly due to vascular disruption: in utero documentation. Pediatrics 78:85-97 18. Jung JH, Graham JM, Schultz N, Smith DW (1984) Congenital hydranencephaly/porencephaly due to vascula disl~ption in monozygotic twins. Pedimrics 73:467-469 19. Hoyme HE, Higginbottom MC, Jones KL (1981) Vascular etiology of disruptive structural defects in monozygotic twins. Pediatrics 67:288-291 20. Yoshioka H, Kadamoto Y, Mino M, Morikawa Y, Kasubuchi Y, Kusunoki T (1979) Multicystic encephalomalacia in liveborn twin with a stillborn macerated co-twin. J Pediatr 79:798-800 21. Melnick M (1977) Brain damage in survivor after in-utero death of monozygous co-twin. Lancet II: 1287

Objective. Unplanned extubation (UEX) is a potentially serious complication of mechanical ventilation. Limited information is available regarding factors that contribute to UEXs and subsequent reintubation of children. We monitored UEXs in our pediatric intensive care unit (PICU) for a 5-year period to assess the incidence and patient conditions associated with UEX and to evaluate whether targeted interventions were associated with a reduced rate of UEXs.Methods. Over a 5-year period, demographic and clinical information was collected prospectively on all patients who required an artificial airway while admitted to the PICU. Additional information was collected for patients who experienced an UEX. Educational sessions and care management protocols were developed, implemented, and modified according to issues identified via the monitoring program.Results. From a total of 2192 patients who required 13 630 airway days (AWD), 141 (6%) patients experienced 164 UEXs. The overall rate of UEX for the study period was 1.2 UEXs per 100 AWD, and this rate decreased from 1.5 in the first year to 0.8 in the last year. UEXs were more common in children who were younger than 5 years (1.6 vs 0.6 UEX per 100 AWD) compared with older children. The UEX children experienced significantly longer length of mechanical ventilation (6 vs 3 days) and longer length of PICU stay (8 vs 4 days) compared with non-UEX children. Forty-six percent of the UEXs occurred in patients who were weaning from mechanical ventilation, and 22% of those patients required reintubation.Conclusions. We conclude that UEX in pediatric patients is associated with longer length of mechanical ventilation and length of stay in the PICU. A continuous quality improvement monitoring and educational program that identified high-risk patients for UEX (younger patients) and patients who were at low risk for subsequent reintubation (weaning patients) contributed to a reduction of these potentially adverse events.

Background: Extracorporeal life support (ECLS) has been used for post-cardiotomy rescue, but its use as a bridge to heart transplantation (OHT) in patients with postsurgical or end-stage ventricular failure remains controversial.Methods: Records were reviewed for patients receiving ECLS for. ventricular failure from January 1991 to August 2001. Patients listed for OHT were analyzed separately. Listing, for OHT requirements were improbable myocardial recovery, absence of contraindications (central nervous system damage, high pulmonary resistance, ongoing infection, etc.), and parental consent. Outcome variables included patient demographics, diagnosis, days from ECLS initiation to United Network for Organ Sharing (UNOS) listing (latency), list time, renal function, and survival to discharge.Results: Of 145 patients with ventricular failure who received ECLS, 21 pediatric patients were UNOS listed. Of 124 non-listed patients, 57 (46%) survived to discharge. All but 3 survivors were separated from ECLS in less than or equal to7 days. Twelve underwent OHT and 10 survived to discharge (list time, 6 days; median ECLS time, 14 days). Five had ECLS discontinued without, undergoing OHT (1 later underwent OHT, 2 survived to discharge). Five experienced complications while receiving ECLS and died without undergoing OHT. Six of 9 patients who required dialysis for renal failure died. Of 11 infants listed, 4 were weaned from ECLS without undergoing OHT (2 survived to discharge), 5 had OHT (ECLS support, 4 days; 4 survived to discharge) and 2 died. (ECLS support, 16 and 47 days).Conclusions: (1) Extracorporeal life support can be used as a bridge to OHT (even among the infant population) for at least 2 weeks with acceptable survival and hospital discharge rates, and (2) renal insufficiency with the concomitant requirement for dialysis decreases the likelihood of survival before and after OHT.

STUDY OBJECTIVE:To describe the safety and risks of placing pediatric patients in the prone position during extracorporeal membrane oxygenation (ECMO) for the treatment of respiratory failure.DESIGN:Single-center retrospective cohort study.SETTING:Tertiary pediatric ICUs.PATIENTS:All patients admitted to the pediatric ICU who required ECMO for respiratory failure from 1995 to 2000.INTERVENTIONS:None.MEASUREMENTS AND RESULTS:Medical records for 93 patients representing 95 ECMO runs for treatment of respiratory failure were reviewed. Of these, 63 patients (66%) received intermittent prone positioning. Demographic data and clinical information were recorded. The median age was 12 months, and the median weight was 9.8 kg. There were 962 position changes. Complications surveyed for included bleeding from appliance insertion sites, appliance dislodgment, unplanned extubation, cutaneous pressure ulceration, corneal abrasion, and extreme hemodynamic instability. These complications were noted as to whether they were present prior to the initiation of prone positioning or whether they developed after prone positioning began. Twenty-four percent of patients had bleeding from cannulation sites prior to prone positioning, and 18% of patients had bleeding begin after prone positioning was initiated. Two patients had chest tubes dislodge after prone positioning began, but neither patient had bleeding occur or required reinsertion of the chest tube. There were no unplanned extubations, appliance displacements, development of cutaneous pressure ulcerations, or corneal abrasions associated with prone-positioning maneuvers. No patient had ECMO support removed secondary to the surveyed complications. Eighty-two percent of children who received prone positioning during ECMO for treatment of respiratory failure survived to hospital discharge.CONCLUSION:We found that prone positioning may be used in pediatric ECMO patients without increasing the risk of complications. A multi-institutional, prospective, randomized, controlled study would better evaluate the efficacy of this practice and whether it is associated with a shorter length of ECMO or shorter post-ECMO ventilation and outcome.

Previous studies of extracorporeal life support in pediatric patients have identified variables associated with survival. However, none of these studies focused on extracorporeal life support after failure of high frequency ventilation (HFV). In the present study, we determined variables associated with survival for pediatric respiratory failure patients who received HFV prior to extracorporeal life support, using data reported to the Extracorporeal Life Support Organization Registry from 1992 to 1998. Patients with neonatal diagnoses, immune compromising conditions, or congenital cardiac defects were excluded. The 243 patients who met inclusion criteria had a 58% survival rate (95% CI 48–66%). The mean age was 22 ± 39 months. Mean duration of mechanical ventilation prior to extracorporeal life support was 6.6 ± 5.8 days. Venoarterial extracorporeal life support was used in 72% of the patients; venovenous in 28%. The survival rate for the subset of patients with an oxygenation index greater than 42 cm H2O/torr on HFV (n = 122) was not significantly different from the overall sample. We determined that lower mean airway pressure, lower pressure amplitude, decreased oxygenation index, increased PaO2, and increased oxygen saturation on HFV were associated with increased survival in patients who were subsequently treated with extracorporeal life support.

OBJECTIVE:To examine the use and outcome of extracorporeal life support in children with severe respiratory failure caused by pulmonary hemorrhage. DESIGN:Retrospective case series report. SETTING:Pediatric intensive care unit in a university children's hospital. PATIENTS:Eight patients <19 yrs of age who required extracorporeal life support for severe respiratory failure associated with pulmonary hemorrhage. INTERVENTIONS:Venoarterial or venovenous extracorporeal life support. MEASUREMENTS:Ventilatory support parameters and systemic PaO2/FiO2 ratio before extracorporeal life support, time on extracorporeal life support, number of ventilator days, number of intensive care unit days, number of hospital days, continued bleeding on extracorporeal life support, and survival. MAIN RESULTS:All patients had resolution of their pulmonary hemorrhage within 24 hrs. All patients survived to decannulation, extubation, and hospital discharge. All patients are alive, with follow-up times ranging from 1 to 10 yrs. CONCLUSIONS:Extracorporeal life support is not contraindicated in patients with severe respiratory failure with associated pulmonary hemorrhage and may be a life-sustaining supportive therapy.

OBJECTIVE: To evaluate the safety and efficacy of cisatracurium besylate, a neuromuscular blocking agent in infants zero to 2 yrs of age. DESIGN: An open-label study to evaluate efficacy and safety of cisatracurium as a continuous infusion in infants. SETTING: A tertiary pediatric intensive care unit. PATIENTS: Eleven children, 0-2 yrs of age, requiring prolonged neuromuscular blockade. INTERVENTIONS: Cisatracurium besylate, 0.1 mg/kg, was administered as an intravenous bolus dose and repeated if necessary until a >90% neuromuscular blockade, as determined by train-of-four response, was achieved. Patients were allowed to recover to 90% blockade (I/IV twitch) after the initial bolus and were administered continuous infusion at 2 &mgr;g/kg/min. The continuous infusion rate was adjusted to maintain a train-of-four response of 0-I/IV, with an increase in the rate preceded by a bolus dose of cisatracurium besylate. An electromyographic monitor was used to measure recovery at the end of infusion, when possible. Heart rate and blood pressure were recorded after the initial bolus dose and after changes in infusion rates. Blood samples were drawn at steady-state during cisatracurium infusion at several different times during the study and at the end of infusion for measurement of plasma cisatracurium and laudanosine concentrations. MEASUREMENTS AND MAIN RESULTS: The mean infusion rate of cisatracurium besylate required to maintain train-of-four response of 0-I/iv was 5.4 +/- 3.0 &mgr;g/kg/min. The mean total duration of infusion was 64.5 +/- 36 hrs. Ten percent and complete neuromuscular recovery occurred at 26.6 +/- 10.4 and 74.8 +/- 32 mins, respectively, after discontinuation of infusion. Mean cisatracurium and laudanosine concentrations were 342.5 +/- 169 and 163.3 +/- 116 ng/mL, respectively. Four (37%) patients had undetectable (<5 ng/mL) cisatracurium concentrations at the time of 100% neuromuscular recovery (train-of-four response of IV/IV or no fade at 50 mA on the electromyogram). No significant hemodynamic changes were observed during treatment with cisatracurium besylate (p <.05). CONCLUSIONS: A longer period of recovery from neuromuscular blockade was observed compared with reports of older children. Recovery from neuromuscular blockade after long-term use was not associated with any adverse events in the immediate postinfusion period. Cisatracurium besylate is a safe and effective neuromuscular blocking agent for children 0-2 yrs of age.